The Relationship between Polycystic Ovary Syndrome and Psychological Symptoms

Research Article | DOI: https://doi.org/10.31579/2642-9756/040

The Relationship between Polycystic Ovary Syndrome and Psychological Symptoms

  • Ebru Pinar 1
  • Gul Pinar 2*
  • Ali Ayhan 3

1 1George State University, Psychology Department Atlanta, USA
2* Yıldırım Beyazıt University, Faculty of Heath Science, Nursing Department Ankara, Turkey
3 Baskent University Ankara Hospital, Faculty of Medicine, Gynecologic Clinic Ankara, Turkey

*Corresponding Author: Gul Pinar, Yıldırım Beyazıt University, Faculty of Heath Science, Nursing Department Ankara, Turkey

Citation: Ebru Pinar, Gul Pinar, Ali Ayhan (2021) The Relationship between Polycystic Ovary Syndrome and Psychological Symptoms. J Women Health Care Issues, 4(1); Doi:10.31579/2642-9756/040

Copyright: © 2021 Gul Pinar, This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Received: 27 January 2021 | Accepted: 05 February 2021 | Published: 11 February 2021

Keywords: anxiety: depression; polycystic ovary syndrome; endocrine disorders

Abstract

Background: Polycystic ovary syndrome (PCOS) is a common metabolic and endocrine disease among women of reproductive-age, which cause prone to psychological symptoms.

Aim: The aim of the study is to assess the relationship between PCOS and psychological symptoms.

Method: This case control study was conducted in the Gynecology Clinic of a Private University Hospital, Ankara, Turkey in 2016. The study conducted on patients with PCOS who received therapy in Gynecologic Oncology Center of a Private University Hospital in Ankara, Turkey. A total of 80 women with PCOS were administered The Survey Form, Beck Anxiety Index, and Beck Depression Index.

Results: The PCOS group showed significantly higher scores of anxiety and depression symptoms compared to controls (p<,05). Age, education, marital status and income level were significantly associated with anxiety and depression scores of women with PCOS (p<,05).

Conclusion: Women with PCOS are at risk for anxiety and depression. These results emerged the need of emotional support into clinical process with appropriate interventions as an additional therapy to improve life quality for women with PCOS. Further studies are need to broader understanding of this area.

Introduction

Polycystic ovary syndrome (PCOS) is a heterogeneous disorder that affected by biochemical, psychological, behavioral and environmental factors. PCOS also can be described as the most common endocrinopathy in reproductive age women [1,2]. Clinical signs of PCOS include elevated luteinizing hormone and gonadotropin–releasing hormone levels, whereas follicular-stimulating hormone levels are muted. Although the genetic etiology of PCOS remains unknown, it can be associated with psychiatric disorders [3-14]. Certainly, PCOS can cause inhibition of follicular development and its symptoms may play a role on mental problems as contributing effects such as obesity, facial hirsutism, menstrual disturbance, alopecia, and acne. Especially, PCOS is one of the leading causes of infertility, which may have a negative impact on physiological well-being for many women. As a result of all these health risks and clinical manifestations of disease, current studies confirmed that women with PCOS are significantly more vulnerable to emotional distress such as anxiety, depression, anger, hostility, panic and bipolar disorder, low self-esteem, irritability, tension, social isolation, and eating disorder than others [15-29].

The reproductive and metabolic features of PCOS are sometimes reversible with effectively lifestyle modifications such as weight reduction and regular physical activity. Treatment goals should include regulating ovulation and inhibiting the action of androgens [30,31].

1.1. Aim: The aim of the study is to determine the relationship between PCOS and psychological symptoms.

Method

2.1. Design, time, place, population and sampling

This case control study was conducted in a private University Hospital of Gynecology Unite in Ankara, Turkey. The population of the study consisted of 40 women with PCOS who were referred to the study center between Jan and May 2016. Concurrently, we enrolled 40 outpatients without PCOS when day visited the study center for their routine gynecologic examination as control group in this study. In total, 80 patients were included by convenient sampling in this study.

2.2. Patient selection criteria

The patients; being aged 18 and above, women with PCOS in only cases group (confirmed by the patient chart), did not have a severe illness, physical handicaps and who agreed to participate in the study. Pregnant or postmenopausal women were excluded from the research.

2.3. Data collection and application

Three instruments were used for data collection by the researcher through face-to-face interviews with patients; 1) Survey Form, 2) Beck Depression Index-BDI, and 3) Beck Anxiety Index-BAI. Each interview took about 20-30 minutes.

1) The Survey Form: This form contained 20 questions from review of the literature [5-29], including socio-demographical characteristics (age, education, income, social security, working status, family type, marriage, smoking and alcohol use etc.) as well as their disease history.

2) Beck Depression Inventory-BDI: This Index is a Likert-type scale consisting of 21 multiple-choice items, each scored from 0 to 3. Total score changes between 0 and 63. It is used in clinical applications in order to determine the density of depression. Maximum score of scale is 63 points and the cutting point accepted to determine clinical depression is 17. It was stated that the scores equal to or above 17 are descriptive of depression, which may require treatment with a correctness level of 90%. Distribution of depression score is as follows: 0-10 points show that there is no depression; 11-17 points indicate mild level of depression, 18-29 points indicate medium level depression; 30-63 points indicate severe depression [32]. Hisli (1989) conducted a validity reliability study in 1988 for Turkish application (Cronbach alpha value=,74 [33].

3. Beck Anxiety Inventory-BAI: This index is a Likert-type clinical scale consisting of 21 articles in order to measure anxiety level. The patient is asked to evaluate symptoms for “the last one week including today.” Each symptom is evaluated in a scale consisting degrees "never", "mild level", "medium level", and "severe". Total score changes between 0 and 63 [34]. Ulusoy et al (1998) determined that there is internal consistency in the use of the BAI scale with Turkish patients (Cronbach alpha=,81). Anxiety levels of patients were classified according to the scores received in BAI: 0-17 point indicates mild level, 18-24 point indicates medium level, and 25 and above indicate severe anxiety. This is to say that as BAI scores increase the severity of depression anxiety increases, as well [35].

2.4. Analysis of data

The data were analyzed using the SPSS version 19.0 (SPSS Inc., Chicago, IL). Percentage distribution, means and standard deviation of the scale scores were given in descriptive statistics. The data obtained from subjects in groups were analyzed by using χ2 (chi-square) significance test for categorical variables. For continuous variables, the Student t test and variance analysis were conducted. Tukey HSD tests were performed to identify the source of difference in the variables that are found to be significance in the analysis of variance. P<,05 was considered as significant.

2.5. Ethical explanation

The study was conducted following receiving approval of the Ethics Review Committee of the university where the research was carried out. Participation in the survey was voluntary and anonymous. Prior to data collection, participants were informed about the purpose and duration of the study. Informed consents were obtained and the subjects were informed that they could withdraw from the study at any time.

Results

The socio-demographic data of the subjects are presented in Table 1. The mean age of women was 28.6 ±7.4 (min.19-33). 60 % of women were under 30 years old, 65% were university graduates, 71,2% were single, 68,8% were unemployed, 81,3% had a good income, 58,7% were smoking, and 18,7% were drinking alcohol. There were no statistically significant differences in age, education, working status, family type, and habits between the groups (p>,05), (Table 1). All participants had social status. None of them had children.

* Chi Square test was used.
Table I: Basic characteristics of patients with PCOS and controls

All participants had social status. None of them had children.

In the PCOS group, the total mean score of the women in the BAI was 10,41±4,15 and BDI was 25,13±11,82. In the control group, the total mean score of the women in the BAI was 5,25±4,14 and BDI was 18,80±8,11. Anxiety and depression rates in the women with PCOS were higher than those in the control group (p<,05), (Table 2). The prevalence of depression (65% vs. 30%) and anxiety (80% vs. 40%) was also higher in patients with PCOS compared to the controls (both p < ,05), (Table 3).

*Student t test was used. **p<0>Table 2: BAI and BDI scores in patients with PCOS compared to controls
* Chi square test was used. **p<0>Table 3: BDI and BAI percentage distributions of PCOS and control groups

In Table 4, when some socio-demographic characteristics and anxiety / depression mean scores were compared in the PCOS group, it was observed that the depression (x2= 3,114, p= ,040) and anxiety scores (x2= 4,156, p= ,021) of the 30-year-old and over group were higher than the group under 30 (p<,05). There were significant difference between low income level and depression (x2= 4,341, p= ,045), anxiety (x2= 6,722, p= ,024) score average (p>,05). It was found that women with low education experienced more depression (x2= 5,524, p= ,038) and anxiety (x2= 7,813, p= ,007. Married women had more high level depression (x2= 3,001, p= ,033) and anxiety (x2= 5,213, p= ,030). Although not included in the table, there was no significant relationship between smoking- alcohol habits and anxiety/depression mean scores (p>,05).

* Variance analysis was used (Tukey HSD test in advanced analysis), **p<0>Table 4: Comparison of Socio-Demographical Characteristics of PCOS Group with BDI and BAI Score Averages

Discussion

PCOS is a common disorder affecting up to 15-20% of women in the reproductive age [1,2]. The neuroendocrine systems are crucial not only in reproductive function, but also in mood regulation. Several aspects of the PCOS can potentially cause considerable emotional problems, especially high level of androgen and fertility problems have been linked to higher risk of mental problems [36,37]. In the present study, the prevalence of anxiety and depression was high in women with PCOS. Similar to our findings, other researchers showed that the anxiety among women with PCOS was high level and about one-third of the women suffered from psychiatric symptoms [38-43]. In this study, women with PCOS, especially those who are obese with metabolic syndrome had higher anxiety and depression subscale scores (p<,05). This findings support previous studies indicating that PCOS is clearly associated with psychological disorders such as depression and anxiety. In the same studies also showed that women with PCOS are at risk for disorganized eating behavior, impaired self-esteem and sleeping problems [6,8-10-13,36,41-44]. However, a recent study presented by Cooney et al (2017) reported that the group with PCOS had a 3 fold increased risk of depression and a 4 fold increased risk of anxiety compared to group without PCOS [37]. In a cross-sectional study, women with PCOS had more severe anxiety, negative body image and social phobia compared to controls and lower appearance evaluation was associated with depression [38]. Contrary, other study presented by Benson et al (2008) stated that there were not a connection between PCOS and depression symptoms [40].

In the different studies lifestyle interventions such as regular physical activity, healthy diet, weight loss and habit modifications for women with PCOS have been found to be effective in reducing mild-moderate depression and anxiety [19-21,25,29,30]. Mental problems are undoubtedly a serious complication in women with PCOS. Screening and minimizing emotional symptoms through consultation with an expert is very important, as it can reduce motivation in the management of the disease. Moreover, untreated mental problems may worsen the outcome by increasing the risk of suicide attempts, comorbidity or functional disability, worsening overall symptoms related disease [31,40]. According to the most recent international PCOS management guidelines, educational programs, social support strategies, lifestyle interventions (preferably all three of the following: diet, exercise, and behavioral management strategies) with a multidisciplinary approach, non-pharmacological and complementary/alternative therapy besides medical treatment such as cupping, acupressure, acupuncture, herbal, dietary supplements, yoga, aerobic, and meditation should be recommended in all PCOS patients to enhance quality of life of these women [15,16,28,42-48].

In this study, age, education, income and marital status had influence on the prevalence of anxiety and depression in women with PCOS (p<,05). This study consisted with previous studies showing that the advanced age with low income status or the longer time to PCOS diagnosis predicted increased mental problems. According to the literature, the social pressure to have a child after marriage and loss of regular menstruation are common in many societies during marriage, Therefore, marriage can have social consequence. In addition, this cultural approach may interfere with female role expectations, which may further increase the risk for anxiety and may cause profound emotional distress in affected women as a contributing factor. Prior studies have also established links between emotional distress and socio-cultural characteristics in women with PCOS [9,20,28,31,40]. On the other hand, recently published study by Himelein and Thatcher (2006) on American women with PCOS provided no convincing support for a pivotal role of infertility in terms of mental problems [43]. In addition, other studies comparison between psychological symptoms in women with PCOS showed no significant difference in socio-demographic features [41,42].

Conclusion

In conclusion, PCOS and related symptoms increased risk of depression and anxiety. Therefore, mental problems should be considered in treating women with PCOS as part of comprehensive clinical care for successful engagement at their initial visit. Additional strategies on effective PCOS lifestyle management would be beneficial. Ultimately, further studies with a larger sample are still required to get more information and to confirm these findings.

However, our findings highlight the importance of considering the socio-demographic characteristics and habits for each woman with PCOS to ensure correct approach for alleviating psychological symptoms. Also, the data of this case controlled study were based on psychoanalytic scale of the women by face-to-face interview instead of retrospective patient chart based reports. In this sense, it is thought that the scientific data obtained from this study will greatly emphasize the importance of the subject.

Acknowledgements

The authors would like to express gratitude to the hospital staff for allowing them to conduct this study using their patients and facilities. They also thank the women for taking interest in the study.

Funding

No funding was used for this study.

Competing interest

There are no conflicts of interest.

References

Clearly Auctoresonline and particularly Psychology and Mental Health Care Journal is dedicated to improving health care services for individuals and populations. The editorial boards' ability to efficiently recognize and share the global importance of health literacy with a variety of stakeholders. Auctoresonline publishing platform can be used to facilitate of optimal client-based services and should be added to health care professionals' repertoire of evidence-based health care resources.

img

Virginia E. Koenig

Journal of Clinical Cardiology and Cardiovascular Intervention The submission and review process was adequate. However I think that the publication total value should have been enlightened in early fases. Thank you for all.

img

Delcio G Silva Junior

Journal of Women Health Care and Issues By the present mail, I want to say thank to you and tour colleagues for facilitating my published article. Specially thank you for the peer review process, support from the editorial office. I appreciate positively the quality of your journal.

img

Ziemlé Clément Méda

Journal of Clinical Research and Reports I would be very delighted to submit my testimonial regarding the reviewer board and the editorial office. The reviewer board were accurate and helpful regarding any modifications for my manuscript. And the editorial office were very helpful and supportive in contacting and monitoring with any update and offering help. It was my pleasure to contribute with your promising Journal and I am looking forward for more collaboration.

img

Mina Sherif Soliman Georgy

We would like to thank the Journal of Thoracic Disease and Cardiothoracic Surgery because of the services they provided us for our articles. The peer-review process was done in a very excellent time manner, and the opinions of the reviewers helped us to improve our manuscript further. The editorial office had an outstanding correspondence with us and guided us in many ways. During a hard time of the pandemic that is affecting every one of us tremendously, the editorial office helped us make everything easier for publishing scientific work. Hope for a more scientific relationship with your Journal.

img

Layla Shojaie

The peer-review process which consisted high quality queries on the paper. I did answer six reviewers’ questions and comments before the paper was accepted. The support from the editorial office is excellent.

img

Sing-yung Wu

Journal of Neuroscience and Neurological Surgery. I had the experience of publishing a research article recently. The whole process was simple from submission to publication. The reviewers made specific and valuable recommendations and corrections that improved the quality of my publication. I strongly recommend this Journal.

img

Orlando Villarreal

Dr. Katarzyna Byczkowska My testimonial covering: "The peer review process is quick and effective. The support from the editorial office is very professional and friendly. Quality of the Clinical Cardiology and Cardiovascular Interventions is scientific and publishes ground-breaking research on cardiology that is useful for other professionals in the field.

img

Katarzyna Byczkowska

Thank you most sincerely, with regard to the support you have given in relation to the reviewing process and the processing of my article entitled "Large Cell Neuroendocrine Carcinoma of The Prostate Gland: A Review and Update" for publication in your esteemed Journal, Journal of Cancer Research and Cellular Therapeutics". The editorial team has been very supportive.

img

Anthony Kodzo-Grey Venyo

Testimony of Journal of Clinical Otorhinolaryngology: work with your Reviews has been a educational and constructive experience. The editorial office were very helpful and supportive. It was a pleasure to contribute to your Journal.

img

Pedro Marques Gomes

Dr. Bernard Terkimbi Utoo, I am happy to publish my scientific work in Journal of Women Health Care and Issues (JWHCI). The manuscript submission was seamless and peer review process was top notch. I was amazed that 4 reviewers worked on the manuscript which made it a highly technical, standard and excellent quality paper. I appreciate the format and consideration for the APC as well as the speed of publication. It is my pleasure to continue with this scientific relationship with the esteem JWHCI.

img

Bernard Terkimbi Utoo

This is an acknowledgment for peer reviewers, editorial board of Journal of Clinical Research and Reports. They show a lot of consideration for us as publishers for our research article “Evaluation of the different factors associated with side effects of COVID-19 vaccination on medical students, Mutah university, Al-Karak, Jordan”, in a very professional and easy way. This journal is one of outstanding medical journal.

img

Prof Sherif W Mansour

Dear Hao Jiang, to Journal of Nutrition and Food Processing We greatly appreciate the efficient, professional and rapid processing of our paper by your team. If there is anything else we should do, please do not hesitate to let us know. On behalf of my co-authors, we would like to express our great appreciation to editor and reviewers.

img

Hao Jiang

As an author who has recently published in the journal "Brain and Neurological Disorders". I am delighted to provide a testimonial on the peer review process, editorial office support, and the overall quality of the journal. The peer review process at Brain and Neurological Disorders is rigorous and meticulous, ensuring that only high-quality, evidence-based research is published. The reviewers are experts in their fields, and their comments and suggestions were constructive and helped improve the quality of my manuscript. The review process was timely and efficient, with clear communication from the editorial office at each stage. The support from the editorial office was exceptional throughout the entire process. The editorial staff was responsive, professional, and always willing to help. They provided valuable guidance on formatting, structure, and ethical considerations, making the submission process seamless. Moreover, they kept me informed about the status of my manuscript and provided timely updates, which made the process less stressful. The journal Brain and Neurological Disorders is of the highest quality, with a strong focus on publishing cutting-edge research in the field of neurology. The articles published in this journal are well-researched, rigorously peer-reviewed, and written by experts in the field. The journal maintains high standards, ensuring that readers are provided with the most up-to-date and reliable information on brain and neurological disorders. In conclusion, I had a wonderful experience publishing in Brain and Neurological Disorders. The peer review process was thorough, the editorial office provided exceptional support, and the journal's quality is second to none. I would highly recommend this journal to any researcher working in the field of neurology and brain disorders.

img

Dr Shiming Tang

Dear Agrippa Hilda, Journal of Neuroscience and Neurological Surgery, Editorial Coordinator, I trust this message finds you well. I want to extend my appreciation for considering my article for publication in your esteemed journal. I am pleased to provide a testimonial regarding the peer review process and the support received from your editorial office. The peer review process for my paper was carried out in a highly professional and thorough manner. The feedback and comments provided by the authors were constructive and very useful in improving the quality of the manuscript. This rigorous assessment process undoubtedly contributes to the high standards maintained by your journal.

img

Raed Mualem

International Journal of Clinical Case Reports and Reviews. I strongly recommend to consider submitting your work to this high-quality journal. The support and availability of the Editorial staff is outstanding and the review process was both efficient and rigorous.

img

Andreas Filippaios

Thank you very much for publishing my Research Article titled “Comparing Treatment Outcome Of Allergic Rhinitis Patients After Using Fluticasone Nasal Spray And Nasal Douching" in the Journal of Clinical Otorhinolaryngology. As Medical Professionals we are immensely benefited from study of various informative Articles and Papers published in this high quality Journal. I look forward to enriching my knowledge by regular study of the Journal and contribute my future work in the field of ENT through the Journal for use by the medical fraternity. The support from the Editorial office was excellent and very prompt. I also welcome the comments received from the readers of my Research Article.

img

Dr Suramya Dhamija

Dear Erica Kelsey, Editorial Coordinator of Cancer Research and Cellular Therapeutics Our team is very satisfied with the processing of our paper by your journal. That was fast, efficient, rigorous, but without unnecessary complications. We appreciated the very short time between the submission of the paper and its publication on line on your site.

img

Bruno Chauffert

I am very glad to say that the peer review process is very successful and fast and support from the Editorial Office. Therefore, I would like to continue our scientific relationship for a long time. And I especially thank you for your kindly attention towards my article. Have a good day!

img

Baheci Selen

"We recently published an article entitled “Influence of beta-Cyclodextrins upon the Degradation of Carbofuran Derivatives under Alkaline Conditions" in the Journal of “Pesticides and Biofertilizers” to show that the cyclodextrins protect the carbamates increasing their half-life time in the presence of basic conditions This will be very helpful to understand carbofuran behaviour in the analytical, agro-environmental and food areas. We greatly appreciated the interaction with the editor and the editorial team; we were particularly well accompanied during the course of the revision process, since all various steps towards publication were short and without delay".

img

Jesus Simal-Gandara

I would like to express my gratitude towards you process of article review and submission. I found this to be very fair and expedient. Your follow up has been excellent. I have many publications in national and international journal and your process has been one of the best so far. Keep up the great work.

img

Douglas Miyazaki

We are grateful for this opportunity to provide a glowing recommendation to the Journal of Psychiatry and Psychotherapy. We found that the editorial team were very supportive, helpful, kept us abreast of timelines and over all very professional in nature. The peer review process was rigorous, efficient and constructive that really enhanced our article submission. The experience with this journal remains one of our best ever and we look forward to providing future submissions in the near future.

img

Dr Griffith

I am very pleased to serve as EBM of the journal, I hope many years of my experience in stem cells can help the journal from one way or another. As we know, stem cells hold great potential for regenerative medicine, which are mostly used to promote the repair response of diseased, dysfunctional or injured tissue using stem cells or their derivatives. I think Stem Cell Research and Therapeutics International is a great platform to publish and share the understanding towards the biology and translational or clinical application of stem cells.

img

Dr Tong Ming Liu

I would like to give my testimony in the support I have got by the peer review process and to support the editorial office where they were of asset to support young author like me to be encouraged to publish their work in your respected journal and globalize and share knowledge across the globe. I really give my great gratitude to your journal and the peer review including the editorial office.

img

Husain Taha Radhi

I am delighted to publish our manuscript entitled "A Perspective on Cocaine Induced Stroke - Its Mechanisms and Management" in the Journal of Neuroscience and Neurological Surgery. The peer review process, support from the editorial office, and quality of the journal are excellent. The manuscripts published are of high quality and of excellent scientific value. I recommend this journal very much to colleagues.

img

S Munshi

Dr.Tania Muñoz, My experience as researcher and author of a review article in The Journal Clinical Cardiology and Interventions has been very enriching and stimulating. The editorial team is excellent, performs its work with absolute responsibility and delivery. They are proactive, dynamic and receptive to all proposals. Supporting at all times the vast universe of authors who choose them as an option for publication. The team of review specialists, members of the editorial board, are brilliant professionals, with remarkable performance in medical research and scientific methodology. Together they form a frontline team that consolidates the JCCI as a magnificent option for the publication and review of high-level medical articles and broad collective interest. I am honored to be able to share my review article and open to receive all your comments.

img

Tania Munoz

“The peer review process of JPMHC is quick and effective. Authors are benefited by good and professional reviewers with huge experience in the field of psychology and mental health. The support from the editorial office is very professional. People to contact to are friendly and happy to help and assist any query authors might have. Quality of the Journal is scientific and publishes ground-breaking research on mental health that is useful for other professionals in the field”.

img

George Varvatsoulias

Dear editorial department: On behalf of our team, I hereby certify the reliability and superiority of the International Journal of Clinical Case Reports and Reviews in the peer review process, editorial support, and journal quality. Firstly, the peer review process of the International Journal of Clinical Case Reports and Reviews is rigorous, fair, transparent, fast, and of high quality. The editorial department invites experts from relevant fields as anonymous reviewers to review all submitted manuscripts. These experts have rich academic backgrounds and experience, and can accurately evaluate the academic quality, originality, and suitability of manuscripts. The editorial department is committed to ensuring the rigor of the peer review process, while also making every effort to ensure a fast review cycle to meet the needs of authors and the academic community. Secondly, the editorial team of the International Journal of Clinical Case Reports and Reviews is composed of a group of senior scholars and professionals with rich experience and professional knowledge in related fields. The editorial department is committed to assisting authors in improving their manuscripts, ensuring their academic accuracy, clarity, and completeness. Editors actively collaborate with authors, providing useful suggestions and feedback to promote the improvement and development of the manuscript. We believe that the support of the editorial department is one of the key factors in ensuring the quality of the journal. Finally, the International Journal of Clinical Case Reports and Reviews is renowned for its high- quality articles and strict academic standards. The editorial department is committed to publishing innovative and academically valuable research results to promote the development and progress of related fields. The International Journal of Clinical Case Reports and Reviews is reasonably priced and ensures excellent service and quality ratio, allowing authors to obtain high-level academic publishing opportunities in an affordable manner. I hereby solemnly declare that the International Journal of Clinical Case Reports and Reviews has a high level of credibility and superiority in terms of peer review process, editorial support, reasonable fees, and journal quality. Sincerely, Rui Tao.

img

Rui Tao

Clinical Cardiology and Cardiovascular Interventions I testity the covering of the peer review process, support from the editorial office, and quality of the journal.

img

Khurram Arshad